Medical Forms for Our Services

New Patients - Please Upload the Following Below:

1. Forms 1 - 4

2. Front & Back of Insurance Card

3. Front & Back of Drivers License

If you can't upload, please fax over to 631-930-3231

Psychiatry Clients

1 - Patient Intake Form

2 - Notice of Privacy Practices

3 - HIPPA Consent

4 - Telehealth Consent

5 - Physical Clearance For PCP

6 - Permission To Treat Minor

"*" indicates required fields

Name*

Email*

Phone*

Reason for Consultation

New Patient Request

Human Verification

Email

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